Aquifer Discussion

ANSWER

QUESTION

Complete only the History, Physical Exam, and Assessment sections of the Aquifer virtual case: Family Medicine 28: 58-year-old male with shortness of breath.

You are required to answer all the DISCUSSION QUESTIONS listed below in each domain.

DOMAIN: HISTORY
1a) Identify two (2) additional questions that were not asked in the case study and should have been?
1b) Explain your rationale for asking these two additional questions.
1c) Describe what the two (2) additional questions might reveal about the patient’s health.

DOMAIN: PHYSICAL EXAM
For each system examined in this case;
2a) Explain the reason the provider examined each system.
2b) Describe how the exam findings would be abnormal based on the information in this case. If it is a wellness visit, based on the patient’s age, describe what exam findings could be abnormal.
2c) Describe the normal findings for each system.
2d) Identify the various diagnostic instruments you would need to use to examine this patient.

DOMAIN: ASSESSMENT (Medical Diagnosis)
Discuss the pathophysiology of the:
3a) Diagnosis and,
3b) Each Differential Diagnosis
3c) If it is a Wellness, type ‘Not Applicable’

DOMAIN: LABORATORY & DIAGNOSTIC TESTS
Discuss the following:
4a) What labs should be ordered in the case?
4b) Discuss what lab results would be abnormal.
4c) Discuss what the abnormal lab values indicate.
4d) Discuss what diagnostic procedures you might want to order based on the medical diagnosis.
4e) If this is a wellness visit, discuss what the U.S. Preventive Taskforce recommends for patients in this age group.

Dr. Wilson greets Mr. Barley, introduces you, and then excuses himself to go see another patient. He states he will be back for you to present Mr. Barley’s case to him.

You sit down across from Mr. Barley and say, “Hi, Mr. Barley. Thanks for letting me work with you. What name would you like me to use? He answers “Mr. Barley.” You ask, “Do you have any pronoun preferences?” He answers, “I use he/his, and it’s nice to meet you.”

You begin eliciting the history: “I understand you have a cough and shortness of breath. Can you tell me more about it?” “I’ve had a bad cough, mainly in the morning, last winter and this winter. When I cough, this whitish phlegm comes up.” “Okay. Have you noticed anything else that seems to be related to the cough? Things like weight loss, chest pain, or fever?” “No, no fever or chest pain. And I haven’t lost any weight.” “Have you had any nausea, vomiting, or diarrhea?” “No. None of that. I can’t think of anything else.” “Do you have shortness of breath when you are active and when you are at rest?” “I notice it mostly when I go upstairs or walk quickly. It is worse when I go up more than two flights of stairs.” “Have you had in the past, or do you currently have exposure to things that can cause cough, like chemicals or smoking?” “I smoked one to two packs a day for 26 years. I have cut back on my smoking. I’m down to half a pack per day. I am a farmer, and so could have shortness of breath from a chemical or allergen, but I always wear protective gear for any chemicals, dust, or other irritants. I have never had any allergic or other reactions at work or at home.” You congratulate Mr. Barley on his efforts to cut down his smoking. “Do you have any trouble lying flat when you sleep?” “I like sleeping on two pillows, but I don’t need to do it. It just makes my neck more comfortable.” You learn that he has not traveled recently, which could have exposed him to certain types of pneumonia. He also has not been exposed to tuberculosis. You also learn that Mr. Barley has no leg swelling or paroxysmal nocturnal dyspnea (PND). As a farmer, he is very active so deconditioning is not likely. To see if his shortness of breath could be due to a panic disorder, you ask him a series of questions and note that his symptoms are not associated with paresthesia, choking, nausea, chest pain, derealization feeling, trembling or shaking, dizziness, palpitations, sweating, chills, or flushes. You continue by asking about past medical, social, and family histories. “I think I have a clear idea about what brought you in today. Let me ask you now about your health in general.” “Any serious illnesses in the past?” “I’ve only been seen a couple of times for cuts and stitches recently.” He says that he has never been admitted to the hospital as an adult. He had a tonsillectomy when he was 12 years old. He has had no other surgeries and is not taking any medications. He reports no chronic illnesses. “I’d like to ask about your personal life. Tell me about your home life.” “I live with my wife. We’ve been married 35 years.” He tells you also that they have two children who are grown. He runs a farm 30 minutes away from the city. He has a 40 cigarette pack-year history and drinks one beer every few days. “Tell me about your immediate family health history.” “My father died a few years ago, at the age of 70, of a stroke. My mother is alive and I think she has hypertension. I have two sisters who are healthy, and I have two daughters. They are grown and have families of their own.” He reports no family history of skin or colon cancer, diabetes, lung disease, or liver disease (such as an alpha-1 antitrypsin deficiency). To summarize, you say, “you have had a cough with white phlegm for the past two winters and that you have been experiencing shortness of breath with exertion that has been worse for the past two weeks. You may have been exposed to some chemical irritants at your farm, but you have been careful about this. You also smoke cigarettes, and have been cutting down.” He confirms your history. You say to Mr. Barley, “I’m going to do the physical exam, and then Dr. Wilson will repeat it.” He nods assent. Your exam reveals: Vital signs: Temperature is 37.2 °C (98.9 °F) Pulse is 94 beats/minute Respiratory rate is 22 breaths/minute Blood pressure is 128/78 mmHg General: Appears mildly short of breath Head, eyes, ears, nose, and throat (HEENT): Normocephalic / atraumatic, conjunctivae, and sclerae are normal, PERRL, oropharynx is normal. Neck: Supple without masses, lymphadenopathy, or thyromegaly. Laryngeal height measures 2 cm from the sternal notch to the top of the thyroid cartilage upon full expiration. Lungs: Increased AP diameter. Percussion is normal. Inspiratory crackles at the bases, and end-expiratory wheezing diffusely. Heart: Regular rate and rhythm. 2/6 systolic murmur loudest at the right upper sternal border (RUSB) with radiation to the left lower sternal border (LLSB). Abdomen: Bowel sounds normal, no hepatomegaly, no tenderness. Extremities: 1+ pitting pretibial edema. First confirming your findings with his own exam, Dr. Wilson then agrees that Mr. Barley has some suggestive findings consistent with COPD: Increased AP diameter Laryngeal height 2 cm above the sternal notch Expiratory wheezing Dr. Wilson asks, “What test can we do to confirm that COPD is the correct diagnosis?” Answer: Pulmonary function testing Which of the following are the best next steps in management?” Answer: Help the patient to quit or decrease smoking, Prescribe an albuterol metered-dose inhaler on an as-needed basis. Dr. Wilson asks you to consider how you might encourage Mr. Barley to quit smoking and directs you to the Centers for Disease Control website, which contains a variety of resources for clinicians, including a guide on using the “five Asâ€Â of counseling about smoking cessation. You and Dr. Wilson then join Mr. Barley in the room. “Mr. Barley,” begins Dr. Wilson, “from your physical exam and the symptoms you describe, it appears that you have chronic obstructive pulmonary disease, usually referred to as COPD. For us to be sure, however, we would like to test your breathing function. During this test, you’ll be asked to blow into a large tube connected to a spirometer. This machine measures how much air your lungs can hold and how fast you can blow the air out of your lungs.” Dr. Wilson concludes, “OK, Mr. Barley. After your spirometry, we’ll talk about next steps.” You and Dr. Wilson enter the exam room after the two of you agree that you will be the one to inform Mr. Barley of the test results. You begin, “Mr. Barley, the lung-function report shows that your lung function is decreased, and you do have mild COPD. This means that there’s a blockage within the tubes and air sacs that make up your lungs, which makes it harder to exhale or blow out the air after you breathe it in. When you can’t properly exhale or breathe out, air gets trapped in your lungs and also makes it difficult for you to breathe in normally. COPD is usually caused by long-term smoking: once symptoms begin, the damage to your lungs can’t be reversed, but there are ways to prevent further damage and to help you breathe better. For example, we are going to prescribe a medication that you will inhale, so it will go directly to your airways and minimize side effects.” Next, you and Dr. Wilson talk with Mr. Barley about quitting smoking, using the counseling guidance outlined in the handout. You offer Mr. Barley the phone number of your medical center’s smoking cessation program, and Dr. Wilson asks if he can call Mr. Barley in three weeks to ask about his efforts to stop smoking, to which Mr. Barley agrees. But Mr Barley its nor ready to quit smoking nitial Therapy for Moderate & Severe COPD Initial Therapy for GOLD group B In addition to a short-acting beta-agonist (SABA) for symptoms, patients in group B should be given a long-acting beta agonist (LABA) or long-acting muscarinic antagonist (LAMA). Initial Therapy for GOLD group C Patients in group C should begin initial therapy with a LAMA inhaler (evidence suggests that in this group, LAMAs are slightly more effective than LABAs for preventing exacerbations). Initial Therapy for GOLD group D Patients in group D should also begin initial therapy with a LAMA. For patients with more severe symptoms, a combination LABA/LAMA can be started instead. For patients in group D with concurrent asthma/COPD, a combination LABA/ICS may be the best first choice, especially in patients with elevated blood eosinophils >300. The addition of an ICS can reduce exacerbations, especially in those with an allergic component (eosinophils) to symptoms, but can also increase the risk of pneumonia. Follow Up Therapy Follow up should focus on reviewing symptoms (especially dyspnea and exacerbations, which are addressed in different ways), assessing inhaler technique and adherence, and adjusting medications (either adding or subtracting, as needed). For patients with dyspnea despite a long-acting bronchodilator, a second bronchodilator can be added. For patients with exacerbations despite a long-acting bronchodilator, a second bronchodilator or an ICS can be added—an ICS would be most appropriate for patients with a history of asthma or elevated eosinophils, as described above. For patients with dyspnea or exacerbations despite a LABA/ICS combination, a LAMA can be added. A switch to a LABA/LAMA combination can also be considered. For patients with exacerbations despite a LABA/LAMA combination, there are two options: The addition of an ICS, particularly for those with asthma or high eosinophil counts. Roflumilast (a Phosphodiesterase-4 inhibitor) or azithromycin (a macrolide antibiotic) can be added for those without asthma or high eosinophil counts. The cost of many of these inhalers can be a barrier to use. Methylxanthines, such as theophylline, are not recommended unless other medications are not available or not affordable. Oxygen therapy is indicated if room air oxygen saturation at rest is < 88%. Pulmonary rehabilitation and/or a maintenance exercise program may help with symptoms: physical activity is a strong predictor of mortality, so exercise should be encouraged for all patients. Dr. Wilson turns to you and says, “So far, we have introduced pharmacologic therapy to improve Mr. Barley’s symptoms and prevent exacerbations Another goal is to avoid t COPD exacerbations due to preventable infections. Since infection is a common cause of COPD exacerbations, we should offer Mr. Barley immunizations that might avert certain infections.” After reviewing Mr. Barley’s immunization history, Dr. Wilson orders influenza, COVID, and pneumococcal vaccines as well as other age appropriate vaccinations. He then reviews with Mr. Barley instructions for managing his COPD, discussing COPD exacerbation management and when to seek emergency help. He adds, “It will be important for you to return for regular checkups—we will want to make sure that you are healthy overall, because there are other diseases that can occur in people with COPD, for example, cardiovascular disease. The good news for you today is that your blood pressure is normal, and if you are able to quit smoking in the future, that will help your heart as well as your lungs. For your lungs, I would like to perform the pulmonary function tests periodically so we can determine how well you are responding to treatment and if your disease is progressing. And we will also want to support you in being physically active and maintaining a healthy, nutritious diet—good nutrition is especially important in COPD. Do you have any questions?” Mr. Barley says, “Does this mean I’m not going to be able to breathe normally again?” Dr. Wilson replies, “There’s no cure for COPD. And it’s impossible to undo the damage to your lungs. But by quitting smoking and following your treatment plan, you can prevent worsening of your lung function, control your symptoms, reduce the risk of complications, and improve your chances of leading a full and active life.” “In the future, if you are interested and you’re having more trouble with COPD, there are pulmonary rehabilitation programs that can help with your breathing. They typically combine education, exercise training, nutrition advice, and counseling. You would work with physical therapists, respiratory therapists, exercise specialists, and dietitians. I don’t think you need this right now, but I want you to know there’s a whole team of folks ready to help you if you need it, or if you need more support in general. Sometimes a diagnosis like this can be overwhelming—please come talk to me if you feel that way, even if your breathing is doing fine.” Six months later, on your longitudinal rotation with Dr. Wilson, after seeing a different patient with COPD, you ask about Mr. Barley: “In late spring, he developed an acute exacerbation of COPD. I prescribed an antibiotic, because he had severe shortness of breath and cough, with increased phlegm and a color change to the sputum. After that, he decided to sign up for the smoking cessation classes and use nicotine patches. And he quit! He slipped back into smoking for a couple of weeks, but now he’s back to being smoke-free again. We’ll probably repeat spirometry at his next annual visit. The evidence isn’t 100% clear, but GOLD recommends spirometry annually for patients with COPD. If his FEV1 is less than 80% of predicted (indicating a progression to moderate COPD), or if his usual symptoms worsen, or if he has another exacerbation (indicating a progression to Group B or C), we would discuss changing his medications as appropriate, as well as more strongly recommending pulmonary rehabilitation.”